KYC

http://indane.co.in/kycdetail.php?kid=5433886

Distributor : CAPTAIN GAS SERVICE [154405] Consumer Number : 95198 KYC Number : 130109114042154405

Consumer Number Name of Consumer Salutation First Name Middle Name Last Name Date of Birth

: 95198 : SANTOSH KUMAR : Mr. : SANTOSH : : KUMAR : 07/09/1977

Father's Name Mother's Name Name of Spouse(Wife/Husband) Address House No. House Name/Flat Floor No. Housing Complex/Building No. Street/Road Name Area/land Mark City/Town/Village District State Pin Code Telephone No. Mobile Number Email ID

: Rajendra prasad : Rampati devi : snehlata : M.5.FF-3 SEC.12 PRATAP VIHAR,GZB : flat no-3 : first floor : M5 : Pratap vihar : Near dav school : Ghaziabad : ghaziabad : Uttar Pradesh : 201009 : : +91 9711006031 : ksant77@gmail.com

Proof of Address At Least one of the following documents of Proof of Address is Mandatory. Kindly tick the document provided for Proof of Address by customer. Aadhaar (UID) Lease agreement / rent receipt Telephone/Electricity or any other utility bill Self-declaration attested by Gazetted officer Flat allotment/possession letter LIC Policy : No : No : No : No : No : No Driving License No. Voter ID Passport Ration Card House registration document : No : Yes : No : No : No

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KYC

http://indane.co.in/kycdetail.php?kid=5433886

Distributor : CAPTAIN GAS SERVICE [154405] Consumer Number : 95198 KYC Number : 130109114042154405

Proof of Identity Provided by Customer Document Number PAN Number ? Passport ? Driving License? Ration Card ? UIDAI Adhaar No. ? Voter ID (EPIC-Election Photo ID Card)? Id Issued By Central/State Government? : : : : : : NDN1783125 : No Not Verified Image Uploaded Verified By Distributor

Willing to avail the Subsidy on LPG cylinders

: Yes

Bank Name Branch & Address IFSC Code Account Number

: ICICI BANK LTD : SUPERTECH SHOPPRIX,C-134B, SECTOR-61, NOIDA , U.P. 201307 State: UTTAR PRADESH

: ICIC0000253 : 025301502620

Consumer Photo Consumer signature

: :

Declaration: I declare that the information entered by me in the above form is as per the form signed and submitted by customer.

Online 06/06/2013 09:36:47

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